Kernohan-woltman notch phenomenon in acute subdural hematoma.

A 52-year-old right-handed woman with a history of alcohol abuse presented to our institution several hours after she fell approximately 1.5 m (5 ft) from a bed and hit the right side of her head. Her family had noted a progressive right facial droop and right-sided weakness, which prompted her immediate transfer to our institution for further management. On admission, she was noted to be somnolent but arousable, demonstrating confused speech. Both of her pupils were briskly reactive, but her right eye movements were limited, except for a lateral gaze consistent with a partial third nerve palsy. She had a noticeable forehead-sparing right facial droop, and her right-sided strength was notably 4−/5. She maintained full strength on the left side of her body and had brisk localization to painful stimuli in all extremities. Computed tomographic imaging revealed an acute subdural hematoma approximately 15 mm in maximal thickness, 12 mm of midline shift, and right-sided uncal herniation (Figure 1). The patient underwent an emergency hemicraniectomy on the right side of her skull and a subdural hematoma evacuation. In the immediate postoperative period, the patient’s right-sided weakness remained unchanged. Magnetic resonance imaging of the brain (Figure 2) was per formed and demonstrated T2-weighted hyperintensity in the left cerebral peduncle, consistent with damage to the descending corticospinal tracts rostral to the pyramidal decussation. At 3-month follow-up, the patient had achieved complete resolution of her right hemibody weakness and third nerve palsy.